Diverticulosis

Question 1

Four different manifestations of diverticulum

Answer 1

• Diverticulosis - presence of diverticula
• Diverticular disease - symptoms arising from diverticula
• Diverticulitis - inflammation of diverticula
• Diverticular bleed - erodes vessel and causes large volume painless bleed

Question 2

Pathophysiology of diverticulosis

Answer 2

• Aging bowel - naturally weakened over time
• Movement of stool within lumen = increased intraluminal pressure
• = outpouchings of mucosa through weaker areas of bowel
• These areas are usually where blood vessels penetrate to supply bowel and can also happen at junctions of triangular muscle sheets

Question 3

What can then happen within these outpouchings?

Answer 3

• Bacteria can overgrow
• Leading to inflammation of diverticulum = diverticulitis
• These can sometimes perforate –> peritonitis and sepsis

Question 4

What can occur in chronic diverticulitis?

Answer 4

• Fistula can form
• Colovesical or colovaginal are common

Question 5

Complicated vs simple diverticulitis

Answer 5

• Complicated = presence of abscess or free perforation
• Simple = inflam without these^

Question 6

RF for diverticulosis

Answer 6

• Age
• Low dietary fibre - constipation increases pressure
• Obesity
• Smoking
• FH
• NSAID use

Question 7

Diverticulosis symptoms

Answer 7

• Asymptomatic
• Incidental finding on CT or colonoscopy

Question 8

Diverticular disease symptoms

Answer 8

• Intermittent lower abdominal pain
• Colicky
• Relieved by defecation
• Can also have altered bowel ahbit, nausea and flatulence

Question 9

Acute diverticulitis symptoms

Answer 9

• Acute abdominal pain - sharp, localised to LIF, worsened by movement
• Nausea
• Loss of appetite

Question 10

Examination findings for acute diverticulitis

Answer 10

• Localised tenderness
• Systemically unwell - pyrexia
• Localised peritonism if perforated diverticulum

Question 11

What can mask or change symptoms of diverticulitis even if perforated?

Answer 11

• If taking corticosteroids or immunosupressants
• Also if redundant sigmoid colon, pain may be RLQ or suprapubic (too long, needs to fold/twist to fit inside)

Question 12

Diverticular abscess - management

Answer 12

• Occur as part of complicated diverticulitis (AKA paracolic abscess)
• If <5cm - conservative with IV abx
• If any bigger - radiological drainage 1st line
• If complicated multiloculated (or if clinically deteriorate) –> surgery either laparascopic washout or Hartmanns

Question 13

Bedside and bloods for ?diverticulitis

Answer 13

• FBC, CRP, U&E
• Group and save
• VBG
• Urine dip to exclude urological
• Consider faecal calprotectin if diagnosis unclear

Question 14

Imaging for ?diverticulitis and findings

Answer 14

• CT abdomen-pelvis
• Thickening colonic wall, pericolonic fat stranding (increased attenuation), abscesses, localised air bubbles or free air

Question 15

What investigation should never be done in ?diverticulitis

Answer 15

• Colonoscopy - risk perforating

Question 16

Investigation for uncomplicated diverticular disease

Answer 16

• Flexible sigmoidoscopy
• If not suitable, CT colonography is alternative

Question 17

Classification of acute diverticulitis

Answer 17

Hinchey classification

Question 18

Hinchey classification

Answer 18

• Stage 1 - phlegmon or diverticulitis with paracolic or mesenteric abscess
• Stage 2 - diverticulitis with walled off pelvic abscess
• Stage 3 - diverticulitis + generalised purulent peritonitis
• Stage 4 - diverticulitis + generalised faecal peritonitis

Question 19

Management uncomplicated diverticular disease

Answer 19

• Manage outpatient usually
• Simple analgesia
• Encourage oral fluid intake
• Outpatient colonoscopy to rule out masked malignancy

Question 20

Management diverticular bleeds

Answer 20

• Conservative
• If significant bleeding - blood products and stablise
• If fail to respond conservatively - embolisation or surgical resection

Question 21

When can uncomplicated diverticular disease require admission?

Answer 21

• Uncontrolled pain
• Dehydration
• Immunocompromise
• Significant co-morbids
• PR bleeding
• Persistent symptoms >48hrs using conservative management

Question 22

Management acute diverticulitis

Answer 22

Conservative:
* Antibiotics (oral if mild, IV if more severe)
* Liquid diet?
* IV fluids
* Analgesia
* Typically improve within 2-3 days

Question 23

What to do if acute diverticulitis patient seems to deteriorate?

Answer 23

• Reassess - repeat imaging and check for progression/complication

Question 24

Surgical interventions - when for diverticulitis

Answer 24

• Perforation with faecal peritonitis OR
• Overwhelming sepsis

Question 25

Surgical procedure for severe diverticulitis

Answer 25

* Hartmanns * Sigmoid colectomy with formation of end colostomy * Anastomosis with reversal colostomy considered at later date

Question 26

Complications of diverticulosis

Answer 26

* Recurrence of diverticulitis * Stricture * Fistula

Question 27

Diverticular stricture

Answer 27

* Following repeated episodes of acute inflammation * Scarred, fibrotic bowel = benign stricture * Can cause LBO --> sigmoid colectomy urgent or elective dependent on presentation (stenting can be used temporarily)

Question 28

Diverticular fistula

Answer 28

* Due to repeated inflammation * Always require surgery (mostly) * Colovesical or colovaginal

Question 29

Colovesical fistula

Answer 29

* Between bowel and bladder * Present with recurrent UTI, pneumoturia or passing faecal matter in urine

Question 30

Colovaginal fistula

Answer 30

* Between bowel and vagina * Copious vaginal discharge or recurrent vaginal infections